The Missing Ingredient?

February 24, 2016 by Taylor Lougheed | 7 comments

If a restaurant wanted to reduce its food waste, how would it go about it? Would it order supplies on-demand? Work to prevent spoilage? Use local and seasonal products? Educate and encourage the chefs and kitchen staff to use less? All of these initiatives (and many others) could contribute to the noble goal of reducing food waste, but they would still be missing a huge part of the picture…

Similarly, the Ontario government has been asking the question of how it can reduce wasted or inefficient spending in the healthcare system, shrink the deficit, and achieve a balanced budget. Unfortunately their approach has largely attempted to cut the proverbial ‘food waste’ by cutting kitchen staff and cutting funding by capping physician payments, slashing nursing jobs, and shrinking hospital budgets. Certainly you can reduce food waste if you reduce the total kitchen capacity to prepare the food in the first place, but this one-sided approach fails to consider the other side of the equation: Patient accountability.

To highlight my point I ran an unofficial, non-representative, and likely statistically biased little experiment. I crudely tallied the patients I saw over the last week in two different EDs (where I happened to work in the walk-in/non-acute section) and an after-hours clinic. The rough total was just shy of 100 patients (rounded for simplicity).
Of the 100 patients, I tallied three things:
• Number of admissions
• Number of investigations ordered
• Number of prescriptions provided

The (approximate) numbers?
Admissions: 1
Investigations: 5 x-rays, 4 urine dips, 3 throat swabs
Prescriptions: 3 (antibiotics)

While this little study isn’t at risk of being published in the New England Journal of Medicine anytime soon, it does suggest some interesting points to discuss. For example, if <10% of the patients I happened to see had any testing or treatment performed, what was provided to the other >90%? Education and reassurance.
Unfortunately, this acute point-of-care reassurance for patients who are ultimately quite well, is costly and inefficient. So how do we even begin to try to tackle this issue?
I found that this group could be broadly broken down further: the ‘worried mostly-well’s’ and those seeking ’convenience medicine’.

The ‘worried mostly-wells’ aren’t bad people trying to bilk the system. Many of them are genuinely worried about ailments that are fortunately quite minor. A few examples of cases included individuals (or their children) with a few days of fever, cold-like symptoms, and otherwise well hydrated with good overall energy. In fact, this presentation accounted for probably ~50% of all visits. So how do we translate or distill our reassurance into a broadly relayed public education project? How can we teach our patients what a common cold is; how to effectively manage one at home; and when an assessment may be necessary?

The ‘convenience medicine’ shoppers on the other hand, are somewhat more problematic. Their feeling is that in our current age of on-demand everything, a physician’s assessment is something that should be sold on store shelves for everyone’s convenience. These are individuals who feel that medical reassurance for even the most minor ailments is not only reasonable, but is in fact a right. Many, despite even having a family doctor or nurse practitioner, will often attend walk-ins or attend the ED because it suits their schedule. For better or for worse, my brief experience has been that this wave of ‘convenience medicine’ is not only growing, but may even be actively encouraged by government reforms that emphasize same-day access without asking about what is appropriate access. How do we address the growing cost of unnecessary access to care? Furthermore, who even defines what is unnecessary? The government? The voters? Medical professionals?

Certainly there is nothing wrong with identifying and eliminating inefficiencies and wasteful spending – it is an important cause in which we all should have an interest. We need to be looking at the full equation however, and that includes how the system is being accessed. There is this unfortunate perception that our healthcare system is ‘free’ – which continues to be popularized by various media posts. This perception fails to address that a public healthcare system is a shared responsibility amongst all stakeholders – patients included. There is also a clear need to discuss what the merits of same-day access are intended to be (sick patients), and how we begin to tackle the elephant of ‘unnecessary’ access.

After all, if you want to reduce food waste from a restaurant, you can only try so many initiatives in the kitchen before you have to address what’s happening in the dining room.

 

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Photo credit: Kevin Dooley